Use of BIS Brain Monitors in Intensive Care Unit

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Summary

Appropriate administration of sedatives and analgesics in an intensive care unit (ICU) is critical to avoid over-sedation or under-sedation. Monitoring sedation depth helps prevent the effects of overdosing or suboptimal dosing. BIS monitors can measure patient response to sedation based on brain activity signals, but they are not commonly used in ICU settings.

Objectives

The objectives of the innovation project are to measure the present use of BIS in sedation at a specific facility and evaluate patient outcomes for BIS-guided sedation compared to routine clinical assessment.

Method

A limited review of recent studies was performed to obtain evidence for using BIS in ICU. The proposed project will be implemented in an ICU context and will involve a baseline survey of BIS use practices, provider training, Bispectral Index (BIS) guided sedation (treatment), clinical assessment (control), and post-implementation evaluation.

Results

The studies reviewed suggest that BIS can be a useful tool for an objective assessment of sedation levels in ICU patients. Using technology is associated with better clinical and financial outcomes.

Discussion

The need for sedatives is relatively high in ICU settings. Optimal sedation is important to promote recovery, reduce ICU hours, and decrease costs. Research evidence supports the use of BIS for objective assessment of sedation levels to avoid adverse effects of high or low dosage administration. This project will implement BIS monitoring in an ICU to improve patient outcomes and reduce hospital costs.

Problem Statement

Sedatives and analgesics are useful medications for managing pain and anxiety, especially in patients under intensive care. Proper sedation of this population is needed to avoid side effects of overdose or suboptimal dosing. Ensuring optimal sedation is an important clinical goal, but assessing the medication need and level can be challenging. In intensive care units (ICUs), physiological measures are commonly used to ensure correct dose administration and monitor analgesic effects (Bocskai et al., 2020). However, this method is often imprecise; thus, most patients are over-sedated, resulting in a prolonged stay (LoS).

Since its development, Bispectral Index (BIS) has been applied widely in the operating room (OR) for general anesthesia but infrequently in ICU settings. The technology provides objective measurements of a patient’s response to sedatives or analgesics based on brain electrical activity. Thus, BIS data can help monitor sedation depth to avoid over-sedation. This project proposal evaluates the potential application of BIS in ICU settings for palliative care.

Synthesis of Evidence-based Research

A review of relevant studies will provide evidence for using BIS to assess the appropriate level of sedation in ICU patients. Suboptimal sedation in intensive care can result in pain perception, whereas over-sedation causes aspiration, cardiac complications, and prolonged LoS (Bocskai et al., 2020). Thus, effective monitoring of sedation depth is critical for optimal patient outcomes. BIS has been established as an effective alternative method to Richmond Agitation Sedation Scale (RASS) for monitoring real-time response to dexmedetomidine and midazolam, especially by ICU patients at a high risk of over-sedation (Zheng et al., 2018). The RASS scores showed a statistically significant correlation with BIS data in all patients (r = 0.724, p<0.05) at various time intervals, suggesting that BIS is potentially a valid and reliable substitute for RASS given its additional benefits of non-invasion and objectivity.

BIS monitors could benefit ICU patients through better clinical outcomes and reduced medical costs. Bocskai et al. (2020) found that anesthesia guided by BIS protects patients under postoperative care against delirium and cognitive dysfunction. Using the technology also reduces ICU painful events, morbidity, and LoS compared to not employing BIS. It also improves a patient’s comfort, safety, and postoperative recovery from flexible fiberoptic bronchoscopy (Zheng et al., 2018). Therefore, BIS monitoring of sedation depth has significant clinical and financial benefits.

BIS is also potentially more sensitive to deep sedation than RASS. BIS detected deep sedation that had not been identified by RASS in 84.4% of ventilated ICU patients, with a sensitivity rate of 94% (Wang et al., 2017). Thus, BIS monitors may be a viable alternative to the cumbersome serial RASS assessments, especially in resource-poor critical care units. It can reduce workloads for staff by providing accurate diagnostic data for deep sedation.

The high sensitivity of BIS makes it especially beneficial to ICU patients receiving invasive procedures. It can reduce the period of mechanical ventilation, intubation, and bronchoscopy in critical care units (Yousefi-Banaem et al., 2020). Observational metrics of sedation depth in palliative care patients, such as RASS, may be less accurate than objective methods. Barbato et al. (2017) found that compared to BIS, RASS and the patient comfort scale are blunt scales and may not give accurate measurements of discomfort and sedation. In contrast, BIS uses electroencephalography (EEG) data and can detect distress that may not be determined using observational methods.

However, BIS data may be less useful in cases where deep sedation is not desired or electrical noise interferes with EEG values. The BIS index is useful for monitoring sedation depth in comatose patients. BIS values are a strong predictor of a coma in ICU settings (Zheng et al., 2018). The technology is also useful in monitoring brain activity in comatose patients. BIS is also indicated for pathologies such as brain injury, hemorrhage, and stroke (Zheng et al., 2018). EEG data can show the extent of cognitive impairment for prompt intervention. Therefore, research evidence supports the use of BIS monitors to efficiently assess sedation depth, monitor patient comfort, and diagnose brain pathologies of ICU patients.

Goal and Objectives

The goal of this innovation project is to implement evidence-based BIS-guided sedation in the ICU. Applying BIS in practice can lead to optimal sedation and reduce the risk of over- or under-sedation. Further, this technology can be useful for monitoring the cognitive functioning of comatose patients. The objectives of this project are:

Evaluate the efficacy of BIS in assessing discomfort in unconscious patients compared to the RASS scale.
Measure the sensitivity of BIS to measure sedation depth in ICU patients compared to the RASS method.

Market/Financial Analysis

Sedation needs of critically ill patients are high, as sedatives improve their tolerance to assisted ventilation. Analgesics and sedatives are indicated for most ICU cases, increasing the financial costs of treatment. Sedation also reduces respiratory complications and infections that increase 30-day readmissions and hospital costs (Yousefi-Banaem et al., 2020). Procedures such as BIS, which ensure optimal sedation, can reduce patient spending on sedatives compared to the subjective RASS technique.

The cost-effectiveness of BIS monitoring is due to reduced drug and hospitalization costs. Setting up and operating BIS monitoring at an ICU can be expensive. A complete BIS monitor costs about $6,500, while the measuring device retails at $25 (Sedation equipment and supplies, 2017). Thus, the acquisition and maintenance of BIS are quite costly. However, the financial benefits of BIS may offset this cost and improve patient outcomes. In particular, the number of sedative drugs needed at ICU will decrease because of BIS-guided optimal titration. Sedation based on BIS monitoring reduced pharmacy costs by 18% or $150 per patient over a period of eight weeks (Shetty et al., 2018). The number of sedatives such as propofol used declined because drug use was optimized. Therefore, direct hospital costs may decline when BIS is used to monitor sedation depth in ICU patients.

The length of ICU stay is generally lower when BIS monitors. Shetty et al. (2018) found that BIS lowered LoS by as much as four days, indicating that this technique improves recovery times in ICU patients. Additional financial benefits come from the reduced risk of over-sedation or under-sedation. At a higher dose, sedatives cause nosocomial infections and delirium (Yousefi-Banaem et al., 2020). The cost of treating these conditions adds a financial burden to patients and families. On the other hand, under-sedation increases patient discomfort and pain. Optimizing sedation to potentially eradicate costly consequences of over-sedation or under-sedation has clear financial benefits.

Proposed Project Plan

Timeline

This project will be implemented in an ICU setting of a hospital providing inpatient procedures. The population of interest will be nurses providing sedatives or analgesics to postoperative patients. A 6-month timeline of activities proposed in this project is presented in Table 1.

Table 1: Project Timeline

Period	October 2021	November 2021	December 2021	January 2022	February 2022	March 2022
Activity	Ethical approvals (IRB)	A review of BIS usage by ICU nurses – patient charts and number of patients requiring sedation.	Survey of providers – current BIS practices and usage barriers	Implementation of BIS monitoring system and RASS protocol in two patient populations	Provider training and orientation	Project evaluation

Budget

The budget for this project in Table 2 includes the expenditure incurred by the facility for BIS monitors and training costs.

Table 2: Projected Budget

Equipment	Quantity	Price	Total Amount
BIS monitors	4	$6,500	$26,000
Sensors	8	$25	$200
Disposable electrodes	50	$3	$150
Installation costs	–	–	$400
Training
Computer costs (software only)			$1,500
Notebooks and pens	30	$10	$300
Allowance for nurse educators	2	$400	$800
Training manuals/resources	30	$4	$120
Travel
Travel to facility	0.545 X 50 miles round trip		$28
Other Direct Costs	–	–	$100
Total			$29,598

All costs of equipment (BIS monitors, sensors, and electrodes) and installation are by the supplier, SedationKit.com (Sedation equipment and supplies, 2017).

Evaluation/Measurement Plan

Patient Discomfort Measures

An evaluation of the innovation project will determine the success made in achieving the objectives. Patient discomfort or distress will be measured using the Patient Comfort Scale. Scores in clinical measures of comfort range from 0 (full comfort) to 10 (extreme discomfort) (Barbato et al., 2017). This instrument will be evaluated with the Cronbach’s alpha coefficient, and a score of ≥0.7 will be accepted as an indicator of a reliable internal consistency.

Measuring Sedation Depth

EEG data will be used to indicate the sensitivity of BIS to sedation levels. BIS scores range from 100 (conscious) to 0 (unconscious) and thus can be used to indicate the sedative effect of administered drugs (Barbato et al., 2017). The sensitivity of observation measures will be determined using the RASS scale. This tool measures sedation levels ranging from 1 (drowsy) to 5 (unresponsive).

Ethical Implications

The clinical efficacy of BIS for guiding general anesthesia and sedation in ICU settings is established in research. Therefore, patients subjected to routine use (RASS protocol) may be disadvantaged. The LoS, pain level and nosocomial infection rate in this group may be disproportionately higher than in the cohort receiving BIS guided sedation. Additionally, the risk of over-sedation is elevated when subjective sedation assessment methods, such as RASS, are used. Thus, patients may suffer aspiration and long-term cardiac complications that affect their quality of life (Shetty et al., 2018). Under-sedated patients experience pain and discomfort during routine ICU procedures, such as intubation. Nurses have an ethical obligation to alleviate suffering in critical care.

Additionally, measures to reduce harm to the patient are a priority in ICU settings. Thus, the BIS-guided sedation project is aligned with the ethical obligation to reduce patient suffering. The cost of over-sedation to ICU patients and their families is significant. Prolonged LoS, nosocomial infections, and cardiac complications cause an additional burden to individuals and the community. Therefore, from an ethical standpoint, optimizing sedation to reduce LoS and expenditure on drugs is important for hospitals.

References

Barbato, M., Barclay, G., Potter, J., Yeo, W., & Chung, J. (2017). Correlation between observational scales of sedation and comfort and bispectral index scores. Journal of Pain and Symptom Management, 54(2), 186-193.

Bocskai, T., Kovács, M., Szakács, Z., Gede, N., Hegyi, P., Varga, G., Pap, I., Tóth, I., Révész, P., Szanyi, I., Németh, A., Gerlinger, I., Karádi, K., & Lujber, L. (2020). Is the bispectral index monitoring protective against postoperative cognitive decline? A systematic review with meta-analysis. PLoS ONE, 15(2), 1-17.

Sedation equipment and supplies: BIS monitor. (2017).

Shetty, R. M., Bellini, A., Waijayatilake, D. S., Hamilton, M. A., Jain, R., Karanth, S., & Namachivayam, A. (2018). BIS monitoring versus clinical assessment for sedation in mechanically ventilated adults in the intensive care unit and its impact on clinical outcomes and resource utilization. The Cochrane Database of Systematic Reviews, 2018(2), 1-74. Web.

Wang, Z. H., Chen, H., Yang, Y. L., Shi, Z. H., Guo, Q. H., Li, Y.W., Sun, L., Qiao, W., Zhou, G., Yu, R., Yin, K., He, X., Xu, M., Brochard, L. J., & Zhou, J. X. (2017). Bispectral index can reliably detect deep sedation in mechanically ventilated patients. Anesthesia & Analgesia, 125(1), 176–183. Web.

Yousefi-Banaem, H., Goharani, R., Hajiesmaeili, M., Tafrishinejad, A., Zangi, M., Amirdosara, M., & Nashibi, M. (2020). A review of bispectral index utility in neurocritical care patients. Archives of Neuroscience, 7(3), 1-14.

Zheng, J., Gao, Y., Xu, X., Kang, K., Liu, H., Wang, H., & Yu, K. (2018). Correlation of bispectral index and Richmond agitation sedation scale for evaluating sedation depth: A retrospective study. Journal of Thoracic Disease, 10(1), 190-195.

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